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Today’s guest post on Groin Injuries in Hockey Players is from Peter Nelson. Peter is currently working in collegiate hockey and has shown great interest in understanding why groin injuries are so common and what we can do about it. Peter does a great job thinking outside the box and taking a look at the bigger picture. Thanks Peter, great article, I’ll add some of my own comments at the end.

Groin Injuries in Hockey Players: An All-Too-Common Problem With a Not-So-Commonly Known Solution

Being a former competitive hockey player (admittedly not a very good one—fourth line for life!) and working predominately with hockey players in a strength and conditioning capacity for the last few years, it has become clear to me that hockey players and groin injuries go together like the artist formerly known as Ron Artest and his psychiatrist. Gold star if you get the reference. (photo by David Shane)

Examining the Prevalence of Groin Injuries Among Hockey Players

While this relationship exists at almost all levels of the game, it has been particularly well documented in elite players. Several studies have been conducted to assess the prevalence of this specific injury at the professional level. The results have been consistent, and they are troubling.

A 1978 study by Sim et al. concluded that “ice hockey players are at high risk for noncontact musculoskeletal injuries because of the excessive force generated during the acceleration and deceleration phases of skating.”

A 1997 study by Molsa et al. reported that 43% of muscle strains in elite Finnish hockey players were involving the groin region.

A 1999 study by Emery et al. found that “the impact of groin and abdominal strain injury at an elite level of play in hockey is significant and increasing.” According to their data, the rate of groin/abdominal strains in the NHL increased from about 13 injuries per 100 players per year during the 1991-1992 season to almost 20 injuries per 100 players per year during the 1996-1997 season. Furthermore, the recurrence rate was 23.5%, meaning that injuries of this nature went on to plague a significant percentage of players for an extended period of time.

More recently, a study by Tyler et al. found that out of 9 NHL players evaluated, all of whom had suffered from groin injuries, four had sustained multiple strains.

The Long and Short of Groin Injuries: Muscular Imbalances in Athletes

With the strong correlation between hockey players and groin injuries established, it becomes important to understand why this is the case. Many would be quick to attribute it to the violent nature of the sport, but research indicates that this is unfounded. The study by Emery et al. found that upwards of 90% of all groin injuries were non-contact in nature. Others posit that strains are due to the muscles involved being too short and lacking flexibility.

Sports physicians, physiotherapists, and strength coaches who fall under this category often prescribe stretching of the groin musculature to remedy the issue. The study by Tyler et al., however, found that preseason flexibility of the hip adductors, the primary muscles that make up the groin region, did not differ between NHL players who went on to sustain groin strains and those who did not. This indicates that stretching of the groin is probably not an effective approach toward preventing or treating this type of injury.

What the Tyler et al. study did find was that preseason hip adduction strength of the players who sustained groin injuries was 18% lower than that of the healthy players. They also found that adduction strength was 95% of abduction strength in the uninjured players, compared to only 78% in the injured players. This suggests that a muscular imbalance between the weak adductors and the relatively strong abductors plays a large role in groin issues. The Sim et al. study also supports this view, suggesting that “in ice hockey players, adductor strains may be caused by the eccentric force of the adductors attempting to decelerate the leg during a stride.” The researchers further went on to state that “a strength imbalance between the propulsive muscles and stabilizing muscles has been proposed as a mechanism for adductor muscle strains in athletes.”

Detective Work: Delving Deeper to Identify the Root of the Problem

The logical conclusion then should be that the solution is to strengthen the adductors and stretch the abductors, right? Well, yes, but a more in-depth look at the problem is necessary to determine exactly why this imbalance is present in the first place, that way we can most effectively remedy the issue. As a sports physician, physical therapist, or strength coach, you are not truly solving the problem unless you address the root cause.

In order to identify the root cause, it is important to first consider three main concepts. First, it is imperative to understand the biomechanics of skating. This brief excerpt from the study by Sim et al. sums it up very well:

“During the powerful skating stride the hip extensors and abductors are the prime movers, while the hip flexors and adductors act to stabilize the hip and decelerate the limb.”

The second concept to understand is that these specific movement patterns have a profound effect on the relative strength—and consequently length—of the muscles involved. Because hockey players, like most athletes, spend so much time in extension, the spinal erectors become extremely tight. The same is true of the hip flexors, which become tight due to the constant forward lean seen in an “athletic stance” as well as the strength required to overcome the aforementioned eccentric force needed to slow down the leg in the recovery phase of a skating stride.

Consequently, since the hip flexors pull the pelvis down from the front and the spinal erectors pull the pelvis up from the back, the pelvis becomes tilted anteriorly. This lengthens the hamstrings, putting them at a leverage advantage and forcing them to take on more of the load in extending the hips than the glutes. The glutes then become relatively weak, as does the anterior core. The end result is a player with what Janda called “lower-crossed syndrome”, illustrated below, who is at risk for both low back and hamstring injuries.

How does this play into groin injuries? In order to make that connection, you need to understand the third concept, which is a central tenet of the Postural Restoration Institute (PRI): while muscles are often prime movers in a single plane, they must actually be considered as having an effect on movement in all three planes—sagittal, frontal, and transverse.

The perfect example of this is the hip extensors. While the hip extensors are mostly responsible for movement generated in the sagittal plane, these same muscles—most notably the gluteus maximus—function as external rotators and abductors. This is relevant to hockey because the nature of a skating stride requires players to have strong abductors—they are prime movers in this movement—as well as spend a lot of time in external rotation. This tightens both the external rotators and abductors and pulls the hips into chronic external rotation and abduction, or in other words causes them to become “flared”. Adductor muscles like the adductor magnus, which also contribute to internal rotation, become lengthened and, like the hamstrings in the sagittal plane, are put at risk for injury. This clearly fits the theory of a muscle imbalance as the potential contributor to groin injuries, and it becomes clear from the analysis above that pelvic alignment is important in understanding the root cause of this imbalance.

It also makes it apparent that stretching the groin is not only ineffective; it can actually feed right into the problem!

Shifting Into Neutral: Correcting Pelvic Positioning

That brings us to the million-dollar question: how do we fix it? After coming to the understanding that groin issues are caused by pelvic misalignment in all three planes of movement, you can see why I suggested that strengthening the internal rotators and stretching the external rotators is not a comprehensive solution to the problem. We must address muscular imbalances with the triplanar perspective in order to effectively prevent injuries of this nature.

The first plan of attack should be to rectify the imbalances in the sagittal plane. The reason being is simply that extension limits rotation, and since I already explained that hockey players—and athletes in general—tend to live in chronic extension, it makes sense to resolve that problem first in order to maximize the effectiveness of attempts at repositioning an athlete in the other two planes. I group the frontal plane with the transverse plane, even though I am talking about rotation being limited, because there is significant overlap between the prime movers in abduction/adduction and internal/external rotation.

Addressing the imbalances in the sagittal plane is fairly straightforward. I like the approach Mike Robertson takes in identifying two “force couples”. The posterior force couple consists of the anterior core and the posterior chain (primarily the glutes and hamstrings), and these two will be weak in athletes living in extension, as I previously mentioned. Hammering the glutes and hamstrings with exercises like hip thrusts (demonstrated by Bret Contreras below) and Romanian Deadlifts, respectively, will strengthen the posterior chain and tilt the hips posteriorly by pulling them down from the back, the net result being a more neutral alignment since the athlete was in anterior tilt to begin with. With the anterior core, it is important to note that it is the internal obliques, external obliques, and transverse abdominis that are usually weak, as opposed to the rectus abdominis. Strengthening these muscles will tilt the hips posteriorly by pulling them up from the front, also resulting in a more neutral alignment.

The anterior force couple consists of the spinal erectors and the hip flexors, and these two will be tight. Stretching the hip flexors is crucial; this can be accomplished with stretches like the Bench Hip Flexor Stretch, illustrated by Tony Gentilcore. Self-myofascial release can also be useful.

With the Bench Hip Flexor Stretch, the harder the athlete squeezes the glutes and extends at the hips, the greater the stretch on the rectus femoris. Be careful, however, not to allow the athlete to extend at the lumbar spine, as this reinforces the incorrect movement pattern we are trying to move away from.

Stretching the spinal erectors can be accomplished with “prayer position”-type stretches. Self-myofascial release with a lacrosse ball peanut can also be effective. In working with Head Strength Coach Rob McLean and the Pennsylvania State University Men’s Ice Hockey team, we tend to use exercises with movement patterns that inhibit the paraspinals while also activating the anterior core, such as the exercise from the Postural Restoration Institute shown below, demonstrated by Kevin Neeld.

In this case, we are killing two birds with one stone in strengthening the weak muscles and teaching the athletes to inhibit the tight muscles (notice how Kevin’s back is rounded; this helps to inhibit the spinal erectors) at the same time. You can also see that in the video there is a ball between Kevin’s knees—this is to activate the internal rotators/adductors, which I will discuss next.

Addressing the frontal and transverse planes when it comes to fixing pelvic alignment is overlooked too often. Again, we want to strengthen the internal rotators and adductors—the muscles might largely overlap but it is important to pattern both movements individually—and stretch the external rotators and abductors. For internal/external rotation, med ball crushes is a good one to strengthen internal rotation (note that this exercise can also pattern the adduction movement, depending on how it is performed), and knee-to-knee mobilization is good for both activating the internal rotators and stretching the external rotators. Any exercises that target the semimembranosus (the most medial hamstring muscle) will also help strengthen the internal rotation movement. An easy modification to an already great exercise, which I mentioned earlier, that will help in this regard is having athletes internally rotate the legs during the hip thrust. Here at Penn State we have started doing band-resisted hip thrusts with internal rotation, and Coach McLean and I both like how it hits the internal rotators. Considering that it also strengthens the posterior chain, you’re really killing two birds with one stone in repositioning the pelvis with this small tweak.

There are also a number of good exercises for patterning and strengthening the adduction movement. Adductor Side Bridges, demonstrated below by Kevin Neeld, are great in this regard.

The adductor pullback exercise from PRI, demonstrated below also by Kevin Neeld, is another good one.

We have our players perform the adductor pullback exercise only on the left side (so they would be lying on their right side, as Kevin is in the video) to address the left AIC alignment that I mentioned earlier. Doing the opposite by lying on your left side and shifting your right hip forward and externally rotating it (since the right leg tends to be internally rotated) also helps correct this particular alignment.

Conclusion

Simply put, pelvic positioning is an important piece in preventing groin injuries, which affect athletes in all sports, but are especially a problem amongst hockey players. The three main concepts to remember in assessing pelvic positioning in any athlete are 1) understanding the biomechanics of the sport, 2) identifying the effects these movements have on the muscles involved, and 3) considering muscles as contributors to movement in all three planes, even if they are not prime movers in one or more of those planes. These concepts can be applied in order to identify imbalances in an athlete and the effects they have on the position of the pelvis. Once this is accomplished, a program can be designed so that the imbalances can be corrected and the pelvis returned to neutral. After all, neutral is where we want our athletes to be, as that puts them at the lowest risk for injury. And any reputable strength coach knows that keeping athletes healthy is the primary objective in any program. You can’t translate gains in strength and power to the playing field if you’re stuck on the sidelines.

Mike’s Thoughts

I think Peter did a great job with this article, highlighting the need to start thinking about alignment and triplanar function of the body. These are often missed in our critical thinking. The only thing I would add to this great article is that the real goal of working to enhance alignment is to then allow you to train the body in better neutrality. We may not function in neutral, but you don’t want to be stuck in our poor alignment. You want to be able to get out of your asymmetry when needed.

Every athlete I have worked with that is “stuck” in their asymmetry is prone to recurrent injuries. We’ve all had them, right? The person that just keeps straining their groin, or hamstring, etc. Take a step back and think of the 3 principles that Peter summarizes in his conclusion.

If you like information like this, I’ve discussed concepts like triplanar training of the glutes. These are some of the fundamental principles in my Functional Stability Training of the Lower Body program with Eric Cressey. We discuss a lot of concepts related to alignment, triplanar function of the body, and training the body in 3D.

About the Author

Peter Nelson is a Strength and Conditioning Staff Intern with the Pennsylvania State University Men’s Ice Hockey Team. He graduated in 2012 from Phillips Academy Andover, and is currently a sophomore at Penn State’s University Park Campus. Peter is a former competitive hockey player, having played for Andover’s Varsity Hockey Team for three years in Division 1 of the New England Prep School Ice Hockey Association. While he no longer plays competitively, his longtime involvement in sports has driven his interest in research fields such as nutrition and strength and conditioning. He has previously interned at NIKE SPARQ-affiliated Athletic Evolution in Woburn, MA. Peter is greatly looking forward to continuing to work under Head Strength and Conditioning Coach Robert McLean of the Penn State Men’s Hockey Team and continuing his education in pursuing a career in the health and fitness realm.

Note: I’d like to thank Coach Rob McLean, Head Strength and Conditioning Coach for the Pennsylvania State University Men’s Ice Hockey Team, for taking me under his wing and introducing me to and helping me understand important concepts like those presented by the Postural Restoration Institute. Much of this article reflects what I have learned over the course of the past year while working with him and the hockey team as an intern. I sincerely appreciate the opportunity.

Baseball pitching appears to the general public to be mainly an upper-body movement. However, researchers have found that like many rotational movements such as golf swings and tennis serves, it involves the lower body and trunk musculature extensively. In fact, according to a theory known as proximal-to-distal sequencing, the pitching motion is actually initiated by the lower body and progresses through the core before accelerating the arm and finally the hand.

What is proximal-to-distal kinematic sequencing?

Researchers have suggested that rotational movements such as the baseball, golf or tennis swing follow proximal-to-distal kinematic sequence. Proximal to distal kinematic sequencing is where a motion is initiated by the larger, central body segments and then proceeds outward to the smaller, more distal segments, such as the arms.

While the concept is relatively clear, the terminology varies. Callaway (2012) has noted that researchers have referred to proximal to distal sequencing as kinetic linking or the kinematic sequence and in a recent article, Spaniol (2012) referred to the same principle as “sequential kinetic linking.”

In any event, where optimal proximal-to-distal kinematic sequencing occurs in sport, the pelvis is rotated using the leg and hip muscles. The pelvis accelerates but then quickly decelerates as it transfers energy to the torso. The same pattern is repeated with the torso and the arm and then the arm and the hand, club, bat or racket. Where the kinematic sequence is out-of-order, it is thought that energy is lost, performance decreases and other body segments step in to compensate, which can lead to injury.

What do we know about the role of the lower body in baseball pitching?

While the principle of proximal-to-distal kinematic sequencing indicates that there is a sound theoretical basis for the role of the lower body in baseball pitching, few studies have actually investigated either the forces or the muscle activity involved.

In fact, there are only four studies regularly referenced when discussing the role of the lower body muscles in baseball pitching: MacWilliams (1998), Yamanouchi (1998), Campbell (2010) and Oliver (2010). The studies by MacWilliams and Oliver investigated aspects of proximal-to-distal kinematic sequencing that are seen in baseball pitching, while the studies by Campbell and Yamanouchi looked more generally at the involvement of the leg musculature.

What does the research say about proximal-to-distal kinematic sequencing in pitching?

Is leg drive correlated with wrist velocity?

MacWilliams (1998) investigated the full-body kinematics and kinetics of 7 baseball pitchers using force plates to record leg drive and a five-camera motion analysis system for recording the joint angle movements. Most significantly, they found that wrist velocity correlated significantly with leg drive.

The researchers therefore concluded that the lower body has an important role in increasing the speed of the throwing motion and supports the use of the proximal-to-distal kinematic sequencing model in any biomechanical analysis of baseball pitching. They therefore proposed that strengthening the lower body is important for enhancing pitching performance and avoiding injury.

Are the gluteals correlated with torso rotation during pitching?

Oliver (2010) investigated the muscle activity of the gluteals and explored the relationship of the gluteals to pelvis and torso kinematics during baseball pitching. The researchers found that the activity of the gluteus maximus was directly related to the rate of axial pelvis rotation and also that it was indirectly related to the rate of axial torso rotation.

This study therefore also supports the use of the proximal-to-distal kinematic sequencing model in any biomechanical analysis of baseball pitching. Additionally, it implies that training the gluteals should be a specific focus of baseball pitchers. Optimal exercises for the gluteus maximus include the squats, trap bar deadlifts, hip thrusts, and back raises. However, the gluteus maximus can and should be strengthened in the transverse plane via core rotational movements such as the band hip rotation. See Mike’s article on training the glutes in multiple planes of motion.

What does the research say about leg muscle activity in pitching?

Are the adductors active during pitching?

Yamanouchi (1998) investigated the muscle activity of various upper and lower body muscles during a baseball pitch performed by 10 baseball players and 10 untrained subjects. He used surface electrodes to measure the electromyographical (EMG) activity and normalized the signal against a maximum voluntary isometric contraction (MVIC). He separated the baseball pitching movement into just two phases divided by the point at which the non-pivoting leg landed. The activity of the thigh muscles reported by Yamanouchi is shown in the chart below. Unfortunately, he did not record the activity of the gluteals or hamstrings.

Yamanouchi concluded that his findings were consistent with reports that pitching can lead to problems with the adductor muscle group. He therefore suggested that strengthening the adductor and the antagonist abductor groups could therefore be useful for enhancing pitching performance and avoiding injury.

Most leg muscles are very active during pitching

Campbell (2010) investigated the muscle activity of the biceps femoris, rectus femoris, gluteus maximus, vastus medialis and gastrocnemius during the baseball pitching motion. The researchers used surface electrodes to measure the EMG activity in 11 highly skilled baseball pitchers and normalized the data against MVICs. Rather than the two-phase division used by Yamanouchi, they divided the pitching action into four phases, although the data can be restated to be comparable with the two phases used by Yamanouchi, as shown in the chart below.

The researchers concluded that muscle activity in both the stride and pivot legs reached extremely high levels during the baseball pitch and was generally very high throughout. They therefore suggested that since pitchers must perform over 100 pitches per game, this implies that pitchers need a high level of maximal strength/power as well as a high degree of muscular endurance. They therefore recommend training the lower body of baseball pitchers to increase strength, explosive power and muscular endurance.

What can we conclude?

From this admittedly small body of research, we can suggest that:

Proximal-to-distal kinematic sequencing seems to occur during baseball pitching, with the movement being initiated by the legs, transferred through the pelvis to the torso, through the arm and finally into the hand.

Leg drive is therefore important for pitching velocity. Improving the strength and power of the legs should consequently transfer to faster pitching performance.

Since pitchers may have to perform approximately 100 pitches per game, some degree of muscular endurance training for the legs could be beneficial.

While all leg muscles are very involved in the pitching action, the activity of the gluteals is strongly correlated with pelvic axial rotation velocity, suggesting that specific gluteal training may be worthwhile. A variety of gluteal exercises from multiple vectors is needed for optimal performance.

The adductors may be more involved in the pitching movement than in most standard resistance-training exercises, suggesting that specific exercises should be used to focus on these muscles to help improve performance and avoid injury.

Mike’s Thoughts

Chris wrote an outstanding article as usual. Obviously, as you can see, the leg strength and power is pretty important to baseball pitching. The concept of the proximal to distal kinetic chain sequencing is likely one of the many important factors involved with baseball pitching. Why is it that some of the brightest people in the world can flawlessly understand baseball pitching biomechanics yet can’t pitch successfully! Heck, I am one of the guilty! It’s not that I do not understand how to throw, it’s that I have an imperfect sequence of events that result in a less than ideal fastball! So, while leg strength and power are important to baseball pitching, we can’t forget about training this sequence. This is why proper coaching at a young age and proper strength and conditioning programs that understand this concept are necessary.

In regard to our training programs, these studies demonstrate the need to emphasize the legs, and should give guidance on what specific muscles to focus on. Chris states it well, however, I will further reinforce his comments that we need to train the legs, but also focus on leg work outside of the sagittal plane.

About the author

Chris Beardsley is a biomechanics researcher and author of a book about scientific posterior chain training. He also writes a monthly review of the latest fitness research for strength and sports coaches, personal trainers, and athletes. Thanks for contributing this article on Why are Leg Strength a Power Important in Baseball Pitching!

Last week we talked about the kinetic chain ripple effect theory and how the kinetic chain has an impact throughout the body, but more of an impact closer to the source of dysfunction. For this week, I wanted to discuss 3 common injuries that we all see that may actual just be a symptom, and not the actual injury or source of dysfunction.

As a general rule of thumb, we should probably consider that many of our traditional “injuries” that seem to be relentless and not responsive to treatments may actually be coming from elsewhere in the body. Think back to how patellofemoral pain has been referred to as “the black hole” of orthopedics and how surgery and rehabilitation to correct patella alignment is often unsuccessful. Perhaps patellofemoral pain is actually just a symptom and not the source of dysfunction.

Below are what I have found to be 3 common “injuries” that may actually just be symptoms from dysfunction somewhere else within the kinetic chain. There are many more than 3, but these are likely to be some of the most common that you may encounter. Feel free to leave a comment of more examples that you have encountered. Furthermore, all three fit into the kinetic chain ripple effect theory as the source of dysfunction is pretty close to the location of symptoms

Groin Pain – Source: Hip Joint

I have to admit that in my career I have been stumped by groin strains that seem to be difficult to treat or frequently reinjured. I am sure we have all seen this in our practices, groin pain that doesn’t really look like a groin strain, but what is it? As our understanding of the hip has improved, we find that many people with intra-articular hip joint pathology present with groin pain, which is a common pain referral pattern from the hip joint.

Next time you have a patient with groin pain, clear the hip, you’ll be surprised how many times we find that the symptoms are coming from the hip and that will drastically change our treatment program.

Lateral Epicondylitis – Source: Cervical Spine

Another commonly misdiagnosis that I have seen involves lateral epicondylitis. The C6 nerve root is one of the most commonly involved nerve roots involved in cervical radiculopathy as it exits between the 5th and 6th vertebrae. Any radiculopathy from this nerve root can cause weakness in wrist extension. I have seen even a subtle loss of strength of wrist extension cause a raging lateral epicondylitis. Sometimes this weakness is so subtle that the person doesn’t even realize they have weakness until it is too late. We continue to function and use our hands with this weakness and overload the area. So, we can treat the heck out of the lateral epicondylitis, but if we don’t solve the nerve root issue at the cervical spine we will never regain the wrist extension strength that is needed to decrease the symptoms of lateral epicondylitis.

Patellofemoral Pain – Source: The Hip

We’ve spent a lot of time discussing the contribution of the hip has on symptoms of patellofemoral pain. [If you haven’t yet, this would be a great time to sign up for my newsletter and receive a bunch of goodies, including my eBook on Solving the Patellofemoral Mystery.] Over the last several years, we have made a giant leap in our understanding of why some forms of patellofemoral pain occurs. More often than not, weakness and dysfunction of the hip muscles, specifically the abductors and external rotators, is a leading cause of biomechanical faults at the knee and subsequent patellofemoral pain. Similar to lateral epicondylitis above, you can treat the symptoms all day but you aren’t going to solve the problem if you don’t address the source, weakness and dysfunction of the hip.

Take Home Message

I’m sure that many of my readers have observed all of the above findings. Please do comment and add more examples. So what is the take home message? For the younger clinicians in the audience, I guess it would have to be that we should probably take a step back a rethink all of the injuries that we see that we consider “difficult to treat” or “unrelenting” such as lateral epicondylitis and patellofemoral pain. Maybe we need to think of the bigger kinetic chain principle. Perhaps we are only treating the symptoms and not the true source of the dysfunction. So next time you seem to have a patient that is not responding to your treatments, take a step back, re-evaluate and assess elsewhere in the kinetic chain and make sure that you haven’t missed the true source of the person’s symptoms.

Groin strains and other injuries are very commonly observed in sports, and have been reported to cause up to 16% of injuries in sports like soccer. For those that work with athletes and who have seen these injuries, you know that groin strains can be tricky and often times become a recurrent problem. Thus, it is important to identify risk factors associated with groin injuries to assist in identifying those at risk for injury as well as serving as a potential criteria to return to play.

A recent study from the American Journal of Sports Medicine followed 508 soccer players over the course of one season in an attempt to identify potential factors correlating to groin injury. The authors examined several functional tests (such as jumpy tests and a 40-m sprint) a several clinical examinations including strength, flexibility, and palpation of the hips and lower extremity muscles.

10% of players followed sustained a groin strain. The authors demonstrated that the two most significant risk factors were:

History of previous groin injury – those with a history of previous groin injuries were twice as likely to sustain another groin injury

Weak adductor muscle – those with weak adductor muscle groups show a 4x greater chance of sustaining a groin injury.

Clinical Implications

Several studies in the past have shown similar results in regard to previous injuries and this is one of the main things I preach when developing and implementing injury prevention programs:

Therefore, attempting to prevent injuries is key. The second component of this study is a good step in that direction. Adductor weakness had a very large contribution to groin injuries. I think we could also extrapolate this information to other muscle groups as well, such as the quad or hamstring. The way I think of it is that a healthy athlete with muscle weakness or imbalance is still going to perform at 100% intensity. But if a specific muscle group was at, perhaps 80% strength, something has to give and a strain occurs.

This information really underscores three take home messages for me:

Past injuries are going to lead to future injuries, often times there was a reason this person was injured the first time, right?

We need to do our best to identify those at risk for injuries to prevent this future cycle of injury and reinjury – this includes screening for muscle weakness and imbalances

We need to make sure that the athlete returns to activities when they have restored this weakness or imbalance. I bet one of the reasons that these injuries continue to reoccur is because we far too often rely on pain as our criteria to return to play. Just because the athlete is asymptomatic does not mean they are ready to compete.

What have you found to be helpful in reducing these reinjuries? What do you do to screen for lower extremity imbalances? Have you found them to be effective in preventing injuries?

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